Inspection on 24/05/05 for Hillswood Lodge

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hillswood Lodge 26/01/09

Hillswood Lodge 14/07/06

Hillswood Lodge 16/11/05

Hillswood Lodge 18/01/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hillswood Lodge 9 The Close, Endon, Stoke on Trent Staffordshire ST9 9JH Lead Inspector Rachel Davis Announced 24 May 2005 09:35 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hillswood Lodge Address 9 The Close Endon Stoke on Trent Staffordshire ST9 9JH 01782 504637 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hillswood Care Limited not applicable Older Persons Care Home 16 over 65 4 16 Category(ies) of DE(E) registration, with number OP of places Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18 January 2005 Brief Description of the Service: Hillswood Lodge is a residential care home offering 16 places for older people; four of these may be for service users with dementia over the age of 65. There was one vacancy at the time of this inspection. The home is a large detached property located in the centre of Endon situated at the top of a private drive. Local amenities are within a short walking distance and the local towns are accessible by car or public transport. Both the exterior and interior of the property are very well maintained; the home is exceptionally clean and the décor is set to a high standard. The service users are offered easy access to all areas of the home by the use of grab rails and a lift. All bedrooms meet the required sizes set out by the national minimum standards and are equipped with suitable fixtures and fittings. The bathrooms and toilets are well located and offer appropriate equipment and facilities. Communal areas are spacious and comfortable; one of the lounge areas has french doors opening onto a large patio area, overlooking a mature and well-kept garden. Adequate parking is available. Hillswood Lodge is owned by Mr John Howard and Sandra Seabridge is presently going through the process of registering with the Commission for Social Care Inspection as the manager, this will be completed by July 2005. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 7 hours. A partial tour of the home was undertaken, followed by a walk round the exterior of the property. Three service users, staff on duty, a visitor and the manager were spoken to in depth. Feedback cards were received from service users, their families and one was received back from a placing officer (social worker). Case tracking of two care plans was undertaken. Some staff records were examined and observation of planned activities took place. The inspector ate lunch with the service users and observed the senior staff administer medication appropriately. What the service does well: Being quiet small in registration and size the home is able to provide a cosy and friendly environment. People who use the service said that they were happy with the care they received. ‘The home cares for all of us and would not betray our trust’ ‘I am happy and comfortable’ ‘I am so happy I chose to live here’ were some of the comments returned to the inspector. Privacy and dignity is upheld within the home, direct observation, service users comments, information from visitors and staff practice confirmed this to be an accurate account. Staffing levels were as required, the inspector observed the staff to be delivering a high standard of care and attention to the service users. Staff were also heard offering choice and enabled the service users to make decisions and as many choices as they were able in their daily lives. The registered provider Mr Howard visits the home and forwards the Regulation 26 report to the Commission For Social Care Inspection on a monthly basis. This evidences the home self audits and improves both the service delivery and environmental standards as required. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 6 The manager has worked hard to ensure the standards are maintained and requirements made at the last inspection have been met. The home is run in an organised manner with service users at the heart of decision-making. The home is kept exceptionally clean and is a credit to the staff; service users confirmed that their bedrooms were cleaned very regularly. They are encouraged to bring in their own possessions and furniture as appropriate. Pre assessment and care planning information for each service user is detailed and now covers all areas of individual need including health care monitoring. Care plans are reviewed monthly. A choice of menu is available every day and those service users asked said that the food provided was very good. The service users spoke highly of the staff team and respectful attitudes were observed, whilst both enjoying a healthy banter. The staff team and service users spoke highly of the manager and her support and dedication. What has improved since the last inspection? What they could do better: The Home must ensure that Criminal Record Bureau (CRB) and Pova checks are in place prior to staff appointment; not doing so puts vulnerable people at risk. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 7 The manager must ensure risk assessments are completed in all areas where a hazard has been identified, not doing so leaves both the service users and staff group at risk of injury or harm. The management of infection control needs to be developed. Clinical waste must be dealt with and staff working in the kitchen must be aware of the required temperatures for fridges, freezers and probing. One relative/visitor comment card stated they would like to see more toward activities and recreation. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. Standard 6 is not relevant to this home The newly amended Statement of Purpose and Service User Guide are made available to all service users and their representatives; the information provided gives an excellent overview of what is offered at the home. The manager undertakes effective assessments of potential service users, a full training programme is offered to all the staff affording service users the knowledge that the home can meet their assessed needs. EVIDENCE: The two documents (Service User Guide and Statement of Particulars) need some minor amendments to meet legislation. These include: the relevant experience and qualifications of the registered provider, confirmation that the home does not provide emergency admissions, the arrangements made for consultation with service users about the operation of the care home. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 10 The Service User Guide is available but needs to inform service users and their families about the inspection report and its availability, and contain an accurate complaints procedure. Each service user is offered a written contract /statement of terms and conditions at the point of moving into the home. A confirmation letter is given to the service user or a representative prior to admission or at the time of admission to confirm that the home can meet the individual service users needs. The manager visits potential service users in their current setting and undertakes an assessment. The information gathered at assessment is transferred into the care plans. A pre assessment tool is used to ensure robust information is recorded. A recently admitted service user explained that a meeting had taken place with her family and social worker. They confirmed that ‘ the staff were very nice’ and that they were ‘feeling a little bit better’ Personal care, mobility and medication were documented along with mental state, social interests and carer/family involvement; service users relatives/representatives are also included in this procedure. All necessary specialists needs were arranged as required and documentation was seen to support this. Emergency admissions or intermediate care services are not offered at Hillswood Lodge. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Care planning and health care monitoring is well documented; further work is required to ensure risk assessments are individualised and robust. Medication is well managed and the systems in place safeguard the service user. EVIDENCE: Each service user had an individual plan of care, which included health, personal, and social care needs. The care plans seen at the visit reflected the care that the service users were receiving and these were updated monthly as required. There was evidence to show service users were involved in the plan as far as is possible. Service users spoken to continued to feel that they were treated with dignity and respect. They said the carers encourage them to be as independent as possible but would always intervene where necessary. In some instances, personal risk assessments were in place, however, these require further development as without them in areas such as diabetes or behaviours that challenge for example, service users and staff are placed at risk. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 12 The health care sections of the care plans evidence that needs are closely monitored and medical professionals contacted, if necessary; evidence of weight monitoring was also in the care plans. A large number of service users spoken to revealed that they were very satisfied with the care provided, the Commission for Social Care Inspection witnessed staff knocking on doors, offering service users choice, and allowing them to complete tasks in their own time. A Medications Policy and Homely Remedies policy were held within the home. The medication administered and the systems in place within the home were observed by the inspector and were of a good standard. The staff spoken to had a sound knowledge and understanding, therefore ensuring service users were protected from harm. It was recommended that the pharmacist provide a written report following an audit of the homes medication systems. All staff administering ‘as and when required medication’ (PRN) should record the result whether taken or refused. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Worthwhile activities and stimulation for service users were in place, this provides daily variation and interest for people living in the home. EVIDENCE: An activities plan has been well developed. It was recommended that records should be kept and the names of attendees should also be noted. It was agreed that staff too could identify their own skills and preferences to maximise the potential when offering the activities programme. Through discussion with the manager it was apparent that Sandra has sound ideas to further develop this important area. On the afternoon of inspection some service users were making birthday cards and one service user was painting. At lunchtime service users ate in the dining room and one service user, through choice, remained in the lounge area. The meal was unrushed and choices and second helpings were offered. One comment from a service user confirmed that ‘the food was excellent’. Service users were involved with setting and clearing the tables and a number of them complimented the cook when they left the table. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 14 The kitchen was inspected and found to be clean and tidy. Food supplies were plentiful and fresh fruit and vegetables were available. Records of fridge and freezer temperatures and probing were kept. One fridge was running at a very high temperature and this must be rectified quickly, as the food was not suitably chilled. Service users revealed they were able to come and go freely, the post was seen delivered to service users unopened, one service user is still able to drive and others go out into the community, including church, with family and friends. These findings confirm that service users are offered a flexible routine that are varied to suit individuals expectations, preferences and capacities. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Further information is required to enable service users and their representatives a full understanding of the options available to them relating to making a complaint. The Home has the required information and knowledge relating to abuse procedures and Whistleblowing. EVIDENCE: The complaints procedure is available within the Service User Guide but it does not fully meet the legislative requirements. The procedure needs to confirm that service users may speak with the Commission for Social Care Inspection and make a complaint (if they so wish) at any time, at present it suggests that the Commission would only be notified if the complainant was not satisfied with the outcome. The complaints procedure was sited within the home on the notice board, the manager confirmed this would also be reworded. The complaints log was seen and was up to date with complaints /concerns appropriately logged, this information provides evidence to show that service users are comfortable and feel able to raise their concern or point of view. All the service users and staff spoken with confirmed they would speak with the manager in the first instance and would be confident in doing so. Training and general awareness of how to recognise and report any form of abuse was provided to staff, those spoken to were aware of the procedure. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 16 The inspector discussed Protection of Vulnerable Adults (POVA) with the manager to make certain Sandra had a full understanding. Policies and procedures were not inspected on this visit. A copy of the Department of Health ‘No Secrets’ document will be forwarded by the Commission to the Home. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The Home is very well maintained both externally and internally. Hillswood Lodge is exceptionally clean and tidy; the home therefore provides a safe and comfortable environment for service users. EVIDENCE: A partial tour of the environment was undertaken during this inspection of all of the communal areas, some bedrooms, the gardens and the kitchen area. The home is exceptionally clean and the staff are commended on this. Most areas are in a good state of repair, the proprietor may wish to consider replacing the flooring in the corridor by the toilets in the future and some tiling in toilets would benefit from attention. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 18 All radiators are guarded as required but some required adjustment to ensure that the entire radiator was covered. The manager needs to check all radiator guards are fit for purpose. The bedrooms are equipped to assure comfort and privacy, the manager needs to audit care plans against Standard 24 of he National Minimum Standards to ensure everyone has been offered a bedroom door key, table, 2 chairs etc. This can then be recorded within the individuals care plan to evidence service users choices and preferences. Three bedrooms have been fully redecorated since the last inspection. All service users have been provided with a new bed mattress. The manager verbally confirmed that the requirements made by the fire officer have been complied with; this ensures the safety of those within the home. Service users are offered specialist equipment to maximise their independence, one service user had recently acquired a Zimmer frame and was delighted with the results. The family confirmed to the inspector that the home had requested an assessment to further promote the service users mobility and that the manager Sandra was ‘fantastic.’ The equipment was provided very swiftly and everyone had been kept informed with progress. Toilets and bathrooms are well situated and service users were offered at least two baths a week. Hoists were serviced 6 monthly as required and communal hot water temperatures recorded. This ensures service users are not placed at harm or at risk. The home should consider using paper towels and liquid soap in all communal areas as bars of soap and cotton towels harbour germs, which could result in cross- infection. The home needs to provide foot operated bins for all clinical waste and the outside skip must include a locking devise. The home should not be using latex gloves; these should be discarded and latex free or better still, nitryl gloves should be used. None of the staff or service users have a latex allergy risk assessment on file. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. The Home has a consistent and in the main long established staff team. In most instances the home makes sure all the information needed is on file ensuring the right staff are employed to look after vulnerable people. Staff are highly trained and competent to do their job. EVIDENCE: The staff members spoken to talked about service users in a sensitive and respectful way and understood the need to promote their dignity. An examination of personnel records identified that in most instances the required information was on file. Criminal Records Bureau disclosures (CRB) was not in place on one staff file. The manager is reminded to make certain that all the requirements are met to ensure that service users are not placed at risk through the recruitment procedure. The Home is committed to offering all staff mandatory and specialist training. The manager and one other member of staff are going to be both trained trainers for moving and handling and also fire marshall’s for the home. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 20 National Vocational Qualifications (NVQ) far exceeds the minimum requirements. Out of 13 care staff 10 have NVQ2, and 2 are presently completing it. Five staff have NVQ3 and 1 member of staff is presently completing it. Three staff are enrolled to start NVQ4. The manager is presently undertaking the Registered Managers Award. All of the staff on duty were spoken to during this inspection and observations were also made of staff attitudes and respect towards the service users. This was all very positive. Service users and visitors confirmed this account, comments included: ‘Hillswood Lodge is a very nice home, they care for our relative very well, and they keep us informed at all times’ ‘I feel very happy’ ‘ The staff always say hello, there is good team work ’ ‘When they say, there’s no place like home it’s true’ Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36 and 38. The health, safety and welfare of the service users and staff were promoted and protected as far as reasonably practicable. EVIDENCE: Staff, residents and a visitor told of the manager’s approachability and support. These included ‘ Sandra is fantastic’ ‘Sandra is the ideal mother for all of us’ ‘Sandra knows what she is doing’ The proprietor Mr Howard was also considered approachable and always ‘at the end of the phone’ if necessary. He visits the home and forwards Regulation 26 report to the Commission For Social Care Inspection on a monthly basis as required. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 22 The manager has recently implemented a formal staff supervision system and her records indicate that most of the staff team have attended one supervision session. The staff spoken to during this inspection confirmed that they are well supported by the manager, all reported attending regular team meetings and handovers are held at the end/beginning of each shift. Service users’ financial interests were safeguarded; service users were encouraged to look after their own financial affairs with the support of their families or representative. The health and safety of service users and staff were promoted with safe storage of hazardous substances, regular servicing of electrical and gas appliances, and regulation of the water system. Vigilant staff employed in the home assist with the security of the home. The home still needs to produce an electrical wiring certificate. Health and Safety notices could be seen throughout the home and building and fire risk assessments were up to date. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 4 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 2 COMPLAINTS AND PROTECTION 4 4 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 x x 3 3 x 3 Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 24 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 16 Regulation 22 Requirement The complaints procedure needs to confirm that service users may speak with the Commission for Social Care Inspection and make a complaint (if they so wish) at any time, at present it suggests that CSCI would only be notified if the complaintant was not satisfied with the outcome. All radiator guards within the home must be audited to check they are fit for purpose. The manager needs to provide appropriate facilities for incontinence waste. Foot operated receptacles must be purchased and sited in designated areas throughout the home; a lock for the outside clinical waste skip is required. Staff must not be working in the home prior to CRB and POVA clearance. The home needs to discard latex gloves and replace with safe alternatives. The Statement of Purpose must include all matters listed in Schedule 1 The Service User Guide must Timescale for action 24.6.05 2. 3. 25 26 12(1)(a) 16(1)(k) 1.7.05 24.6.05 4. 5. 6. 7. 29 26 1 1 19(1) (b) (ii) 13(4)(a) 4(1)(c ) 5(d) as required 1.6.05 1.7.05 1.7.05 Page 25 Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 8. 24 23(2)(f) Schedule 4 (10) 13 (4)(c ) 13(4) 9. 10. 15 7 include information relating to a copy of the latest inspection report. The manager must audit the home and the care plans to ensure everyone has been offered the choice of fixtures and fittings listed in Standard 24 The manager must ensure that the fridges run between 0-4 degrees C. The manager shall ensure that all required risk assessments are on each individual service user file following the identification of a hazard or potential risk 1.7.05 10.6.05 ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 12 9 26 9 19 Good Practice Recommendations To consider further development of activity programmes by identifying staffs individual skills and record which service users participate in which activity Request all trained staff to record the PRN medication outcome Consider using paper towels and liquid soap in all communal areas to reduce the risk of cross infection. Request a written report following a medicine audit offered by pharmacist Consider replacement flooring by the downstairs toilets on this years maintenance programme. Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillswood Lodge E09 E51 S59811 Hillswood Lodge V225264 240505 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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